Download Acute Infection Guideline Summary - California Medical Association

Reference Articles
Evidence-Based Management of Acute Respiratory Tract Infections
Community Acquired Pneumonia:
1. Mandell LA, et al. Infectious Diseases Society of America/American Thoracic Society Consensus
Guidelines on Management of Community-Acquired Pneumonia in Adults. CID. 2007;44:S27-72.
2. Drugs for Community-Acquired Bacterial Pneumonia. Med Lett Drugs Ther. 2007;49(1266):62-64.
3. Kobayashi M, et al. Intervals between PCV13 and PPSV23 vaccines: recommendations of the
Advisory Committee on Immunization Practices (ACIP). MMWR. 2015;64(34):944-7.
Nonspecific URI:
Assess for
pneumonia
2016-17
1. Gonzales R, et al. Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract
Infections in Adults: Background, Specific Aims and Methods. Ann Intern Med. 2001;134:479-86.
2. Gonzales R, et al. Principles of Appropriate Antibiotic Use for Treatment of Acute
Respiratory Tract Infections in Adults: Background. Ann Intern Med. 2001;134:490-94.
3. Institute for Clinical Systems Improvement. Health Care Guideline: Diagnosis and Treatment of
Respiratory Illness in Children and Adults. Available at: www.icsi.org. Revised January 2013. Accessed
August 2014.
In the absence of pneumonia, consider the following diagnoses
for adults with acute cough illness.
(see reverse side
of brochure)
Acute Infection
Guideline Summary
Acute Bronchitis
URI or Rhinosinusitis
Influenza During the Season
Acute Bacterial Sinusitis
Dx Criteria:
• Cough dominant
• +/- phlegm
• Rhonchi/mild wheezing common
Dx Criteria:
• Cough plus nasal, throat and/or
ear symptoms
• No dominant symptoms
Dx Criteria:
• If cough + fever + myalgias/
fatigue present, prevalence ≥
60%
Dx Criteria:
• See reverse side of brochure
Acute Bacterial Sinusitis:
1. The Sinus and Allergy Health Partnership. Antimicrobial Treatment Guidelines for Acute Bacterial
Rhinosinusitis. Otolaryngol Head Neck Surg. January, Supplement 2004;130:1-45.
2. Chow AW, et al. IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and
Adults. Clin Infect Dis. 2012;54(8): e72-e112.
3. Snow V, et al. Principles of Appropriate Antibiotic Use for Acute Sinusitis in Adults: Background. Ann
Intern Med. 2001;134:498-505.
4. Slavin RG, et al. The Diagnosis and Management of Sinusitis: A Practice Parameter Update.
J Allergy Clin Immunol. 2005;116:S13-47.
Pharyngitis:
ANTIBIOTICS NOT NEEDED
See reverse for recommendations on antibiotic therapy.
*Adapted from Gonzales R, et al. A cluster randomized trial of decision support strategies for reducing antibiotic use in acute bronchitis. Jama Intern Med. Published online, January 14, 2013. doi:10.1001/jamainternmed.2013.1589
1. Wessels MR. Clinical Practice. Streptococcal Pharyngitis. NEJM. 2011; 364:648-55.
2. Gerber GA, et al. Prevention of Rheumatic Fever and Diagnosis and Treatment of Acute Streptococcal
Pharyngitis. Circulation. 2009;119:1541-1551.
Nonspecific Cough Illnesses/Acute Bronchitis/Pertussis:
Give symptomatic relief such as codeine-based cough suppressants, NSAIDS, multi-symptom OTC medications, and possibly bronchodilators if there is any bronchospasm.
1. Gonzales R, et al. Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract
Infections in Adults: Background, Specific Aims and Methods. Ann Intern Med. 2001;134:479-86.
2. Gonzales R, et al. Principles of Appropriate Antibiotic Use for Treatment of Uncomplicated Acute
Bronchitis: Background. Ann Intern Med. 2001;134:521-29.
3. Hooton T. Antimicrobial Resistance: A Plan of Action for Community Practice. AFP. 2001;63:1034-39.
4. Wenzel RP, et al. Acute Bronchitis. NEJM. 2006;355:2125-30.
5. Centers for Disease Control and Prevention. Recommended antimicrobial agents for the treatment
and postexposure prophylaxis of pertussis: 2005 CDC guidelines. MMWR 2005;54(No. RR-14):1-16.
Caution patients regarding symptoms (such as high fevers and shortness of breath) that indicate more severe disease.
Cellulitis and Abscesses:
Educate and Advise Patients
Most patients want a diagnosis, not necessarily antibiotics. Explain to the patient that most bronchitis is a viral illness, and coughs are either viral or reactive airway disease. It is important to emphasize
that antibiotics may have serious side effects and may create resistance to antibiotics in the patient or their family. This strategy is associated with equal or superior patient satisfaction.
Set appropriate expectations for the duration of symptoms, e.g., cough may last for up to four weeks.
Reserve the use of quinolones when treating acute bacterial sinusitis, acute bacterial exacerbation of chronic bronchitis, and uncomplicated urinary tract infections for patients who do not have
alternative treatment options.
Recommend Vaccination
• Influenza vaccination for all persons >6 months of age, particularly older and younger patients and those with concomitant significant illnesses.
• Pneumococcal vaccination for those with concomitant significant illnesses and all persons ≥65 years old without a pneumococcal vaccine history. Refer to the CMA Foundation’s Adult Vaccine Schedule
for recommended intervals between the pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23).
• Pertussis immunization for all pregnant women of any age with each pregnancy, between 27 and 36 weeks (but CAN be given at any time). Prompt vaccination is recommended for those who
have or will have close contact with an infant <12 months of age (e.g., parents, grandparents, childcare providers, and healthcare practitioners). For all others vaccinate once during the routine
every-10-year tetanus booster.
FOR MORE INFORMATION OR ADDITIONAL MATERIALS, VISIT WWW.AWARE.MD.
Supporting Organizations
Endorsing Organizations
Alameda Alliance for Health
Health Plan of San Joaquin
Inland Empire Health Plan
American Academy of Pediatrics,
California District
California Pharmacists Association
Anthem Blue Cross
CalOptima
Kern Health System
California Academy of Family Physicians
Urgent Care College of Physicians
Care1st Health Plan
L.A. Care Health Plan
Health Net of California
Molina Healthcare of California
1. Stevens DL, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue
Infections: 2014 Update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59 (2):
e10-e52.
2. Swartz MA., Cellulitis. N Engl J Med 2004; 350:904-912
3. Liu, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment
of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children. Clin Infect Dis 2011;
52:1-38.
Guidelines Reviewed:
American Academy of Allergy, Asthma & Immunology (AAAAI)
American Academy of Family Physicians (AAFP)
American Academy of Otolaryngology – Head and Neck Surgery
American College of Physicians (ACP)
Centers for Disease Control and Prevention (CDC)
Infectious Diseases Society of America (IDSA)
Institute for Clinical Systems Improvement (ICSI)
Infectious Diseases Society of America / American Thoracic Society (IDSA/ATS)
Download the free AWARE Compendium App today!
Urgent Care Association of America
For more information visit: www.aware.md
CMA Foundation, 2230 L Street, Sacramento, CA 95816
© 2016-17, California Medical Association Foundation.
T
UL
Repeated studies and meta-analyses have demonstrated no significant benefit from antibiotics in otherwise healthy persons. Antibiotic administration is
associated with allergic reactions, C. difficile infection and future antibiotic resistance in the treated patient and the community.
AD
Best Practices in the Management of Patients with Acute Bronchitis/Cough
Illness
Indications for Antibiotic Treatment in Adults
Pathogen
Antimicrobial Therapy
Antibiotic
Guidelines Reviewed
Outpatient
Community
Acquired
Pneumonia
When NOT to Treat with an Antibiotic as an Outpatient: Consider inpatient admission if PSI score >90, CURB-65 ≥2, unable to tolerate orals, unstable social
situation, or if clinical judgment so indicates.
Streptococcus pneumoniae
Mycoplasma pneumoniae
Haemophilus influenzae
Chlamydophila pneumoniae
Empiric Therapy:
Antibiotic Choice:
•Macrolide (azithromycin or clarithromycin)*
•Doxycycline (alternative to macrolide)
IDSA, ATS, ICSI
When to Treat with an Antibiotic as an Outpatient: Perform chest x-ray (CXR) to confirm the diagnosis of pneumonia.
Evaluate for outpatient management. Consider pre-existing conditions, calculate Pneumonia Severity Index (PSI ≤90 for outpatient management) or
CURB-65 (0 or 1 for outpatient management). Visit www.idsociety.org for more information.
Healthy with no recent antibiotic use risk
factors: macrolide*; consider doxycycline
Presence of co-morbidity or antibiotic use
within 3 months
With Comorbidities:
ß-Lactam Alternatives:
(to be given with a macrolide* or doxycycline)
Sputum gram stain and culture are recommended if active alcohol abuse, severe obstructive/structural lung disease, or pleural effusion.
Respiratory quinolone ß-lactam plus a macrolide*
(or doxycycline as an alternative to the macrolide).
Pneumococcal vaccination should be done following current ACIP recommendations which have been recently updated. Selective use of PCV 13 (conjugated
pneumococcal vaccine) is now recommended in some situations for adults in conjunction with regular pneumococcal vaccine (PPSV23).
Antibiotic Duration:
•High dose amoxicillin or amoxicillin-clavulanate
•Cephalosporins (cefpodoxime, cefuroxime)
•Quinolones – 5 days
•All other regimens – 7 days
Other Alternative:
•Respiratory quinolone (moxifloxacin, levofloxacin 750mg QD)*
Nonspecific URI
When NOT to Treat with an Antibiotic: Antibiotics not indicated; however, nonspecific URI is a major cause of acute respiratory illnesses presenting to primary
care practitioners. Patients often present expecting some treatment. Attempt to discourage antibiotic use and explain appropriate non-pharmacologic treatment.
Viral
Not indicated
Not indicated.
AAFP, ACP, CDC, ICSI
Acute Bacterial
Sinusitis
When NOT to Treat with an Antibiotic: Nearly all cases of acute sinusitis resolve without antibiotics. Antibiotic use should be reserved for moderate symptoms
that are not improving after 10 days, or that are worsening after 5-7 days, and severe symptoms.
Mainly viral pathogens
Not indicated
Antibiotic Choice:
•Amoxicillin-clavulanate (875 mg/125 mg po bid)
AAAAI, AAFP, AAO,
ACP, CDC, IDSA
When to Treat with an Antibiotic: Diagnosis of acute bacterial sinusitis may be made in adults with symptoms of acute rhinosinusitis (nasal obstruction or
purulent discharge, facial fullness or pain, fever, or anosmia) who have any of the three following clinical presentations:
Streptococcus pneumoniae
Antibiotic Duration: 5 to 7 days
Alternatives:
•Amoxicillin-clavulanate (high dose 2000 mg/125 mg po bid),
doxycycline, respiratory quinolone (levofloxacin, moxifloxacin)*
Nontypeable Haemophilus influenzae
Symptoms lasting >10 days without clinical improvement.
Severe illness with high fever (>39°C [102.2° F]) and purulent nasal discharge or facial pain for >3 consecutive days at the beginning of illness
Failure to respond after 72 hours of antibiotics:
Re-evaluate patient and switch to alternate
antibiotic.
For ß-Lactam Allergy:
•Doxycycline, respiratory quinolone (levofloxacin, moxifloxacin)*
Worsening symptoms or signs (new onset fever, headache or increase in nasal discharge) following typical URI that lasted 5-6 days and were initially improving.
Pharyngitis
When NOT to Treat with an Antibiotic: Most pharyngitis cases are viral in origin. The presence of the
following is uncommon with Group A Strep, and point away from using antibiotics: conjunctivitis, cough, rhinorrhea, diarrhea, and absence of fever.
Routine respiratory viruses
When to Treat with an Antibiotic: Streptococcus pyogenes (Group A Strep) Symptoms of sore throat, fever, headache.
Streptococcus pyogenes
Physical findings include: Fever, tonsillopharyngeal erythema and exudates, palatal petechiae, tender and enlarged anterior cervical lymph nodes, and absence of
cough. Confirm diagnosis with throat culture or rapid antigen detection before using antibiotics.
Nonspecific
Cough Illness /
Acute Bronchitis /
COPD
Pertussis
Skin and Soft
Tissue Infections
Urinary Tract
Infection
Group A Strep: Treatment reserved for
patients with positive rapid antigen detection or
throat culture.
Antibiotic Duration: 10 days
Antibiotic Choice:
•Penicillin V, benzathine penicillin G, amoxicillin
Alternatives:
• Oral cephalosporins
For ß-Lactam Allergy:
•Azithromycin*, clindamycin, clarithromycin*
When NOT to Treat with an Antibiotic: 90% of cases are nonbacterial. Literature fails to support use of antibiotics in adults without history of chronic
bronchitis or other co-morbid conditions.
Mainly viral pathogens
When to Treat with an Antibiotic: Antibiotics not indicated in patients with uncomplicated acute bacterial bronchitis. Sputum characteristics not helpful
in determining need for antibiotics. Treatment is reserved for patients with acute bacterial exacerbation of chronic bronchitis and COPD, usually smokers.
In patients with severe symptoms, rule out other more severe conditions, e.g., pneumonia. Testing is recommended either prior to or in conjunction with
treatment for pertussis. Testing for pertussis is recommended particularly during outbreaks and according to public health recommendations (see below).
Chlamydophila pneumoniae
Testing for pertussis is recommended particularly during outbreaks and according to public health recommendations, particularly those at high risk
– teachers, day care and healthcare workers. Persons with exposure to infants (parents, child care workers or family members) should be vaccinated
and tested if they have symptoms. Vaccination per ACIP recommendations is highly encouraged to prevent outbreaks. All pregnant women should be
vaccinated during every pregnancy.
Bordetella pertussis
Cellulitis is almost always secondary to streptococcal species. Treatment can be directed narrowly.
Streptococcus pyogenes
Staphylococcus aureus (methicillin sensitive
and methicillin resistant)
Indicated
Antibiotic Choice:
Incision and drainage.
Cellulitis: Penicillin, cephalexin, dicloxacillin, clindamycin
If significant associated cellulitis, add antibiotics
Abscesses (if moderate cellulitis/erysipelas or fever):
doxycycline TMP/SMX
>50% UTIs caused by Escherichia coli.
Other gram-negative organisms may cause
infection including Klebsiella, Proteus and
Pseudomonas. Gram-positive pathogens
include Enterococcus and group B
Streptococcus, as well as Staphylococcus.
Antibiotic Duration:
Antibiotic Choice:
Cystitis: 3-5 days
•Cystitis: Nitrofurantoin (100mg bid), trimethoprim/
sulfamethoxazole (TMP/SMX)
•Pyelonephritis: fluoroquinolone* (ciprofloxacin, levofloxacin),
trimethoprim/sulfamethoxazole (TMP/SMX)
Abscesses are often secondary to Staphylococcus aureus – including methicillin-resistant Staphylococcus aureus (MRSA. The treatment is primarily drainage and
this is required for larger abscesses. If surrounding cellulitis, treatment should be broadened to cover MRSA. Cultures should be obtained.
Empiric therapy for UTI may be given when urinalysis demonstrates pyuria (positive leukocyte esterase test) or >10 white blood cells (WBCs) per high-power
field (25 WBCs per uL) and urine culture obtained through catheterization or suprapubic aspiration. A positive culture consists of >100,000 colony-forming
units (CFUs) per mL of a uropathogen.
In patients suspected of pyelonephritis, always confirm diagnosis with urine culture and susceptibility test before using antibiotics.
ACP, AAFP, CDC,
IDSA, ICSI
Uncomplicated: Not Indicated
Antibiotic Choice: Not indicated
AAFP, AC, CDC
Chronic COPD:
•Amoxicillin, trimethoprim-sulfamethoxazole
(TMP/SMX), doxycycline
Mycoplasma pneumoniae
Alternatives:
•Chlamydophila pneumoniae, mycoplasma pneumoniae macrolide* (azithromycin or clarithromycin) or doxycycline
Moraxella catarrhalis
Treatment is required for all cases and close
contacts or as directed by health officer
Antibiotic Choice:
•Azithromycin*
CDC
Alternatives:
•TMP/SMX
Pyelonephritis: 5-14 days
IDSA
IDSA
Alternatives:
•Pyelonephritis: ceftriaxone, aminoglycoside
For ß-Lactam Allergy:
•Cystitis: amoxicillin-clavulanate, cefdinir, cefaclor,
cefpodoxime-proxetil, fluoroquinolone
•Pyelonephritis: Oral ß-lactam (less effective) plus initial IV
ceftriaxone 1g or IV 24-hour dose aminoglycoside
*Macrolides and quinolones cause QT prolongation and have an increased risk of cardiac death; Reserve the use of quinolones when treating acute bacterial sinusitis, acute bacterial exacerbation of chronic bronchitis, and uncomplicated urinary tract infections for patients who do not have alternative treatment options.
This guideline summary is intended for physicians and healthcare professionals to consider in managing the care of their patients for acute infections. While the summary describes recommended courses of intervention it is not intended as a substitute for the advice of a physician or other
knowledgeable health care professional. These guidelines represent best clinical practice at the time of publication, but practice standards may change as knowledge is gained.